Provider Demographics
NPI:1972573442
Name:WISE, LOREN M (MD)
Entity Type:Individual
Prefix:
First Name:LOREN
Middle Name:M
Last Name:WISE
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-372-5701
Mailing Address - Fax:269-372-5702
Practice Address - Street 1:5629 STADIUM DR
Practice Address - Street 2:SUITE D
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-1952
Practice Address - Country:US
Practice Address - Phone:269-372-5701
Practice Address - Fax:269-372-5702
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2014-10-10
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Provider Licenses
StateLicense IDTaxonomies
MI4301078298207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICA4396OtherRAILROAD MEDICARE
MI4635894Medicaid
MICA4396OtherRAILROAD MEDICARE
I17713Medicare UPIN